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2 Question #1 How many people in the US have asthma? a. 5 million b. 10 million c. 15 million d million Question #2 Which of the following is NOT an element of the diagnosis of asthma? a. Prescription records b. History c. Spirometry d. Physical exam 2

3 Question #3 Which of the following best describes the typical symptom(s) of asthma? a. Wheezing and chest tightness b. Wheezing, cough, and chest tightness c. Wheeze d. Dry productive cough and nighttime apnea episodes Question #4 Which of the following best describes the basic pathophysiology of asthma? a. Autoimmune destruction of the bronchioles b. Hypertrophy of the small and large airway musculature c. Inflammation and airway hyperreactivity d. Cellular infiltration of the airways 3

4 Question #5 Which of the following is a category in the classification of asthma severity? a. Episodic b. Intrinsic c. Moderate persistent d. Severe intermittent Choose your option below. Next Topic: Overview of Asthma 4

5 Overview of Asthma Asthma 5

6 Asthma is a Disease of Special Interest to Pharmacists Drug therapy is critical to positive outcomes Treatment guidelines exist that detail care/management Undertreatment and inappropriate treatment are major contributors to asthma morbidity and mortality Preventing acute episodes has a proven and quick payoff in reducing hospitalization and emergency room visits Asthma is typically the 1st or 2nd chosen target of disease management programs run by Managed Care Organizations Prevalence of Asthma 20.5 million people in the U.S. Nine million U.S. children under 18 have been diagnosed with asthma More than four million children have had an asthma attack in the previous year Most common chronic disease of childhood (boys > girls) Women affected more often than men Prevalence is decreasing 6

7 Morbidity and Mortality 12.7 million physician office visits and 1.2 million outpatient department visits due to asthma/year 500,000 hospitalizations/year 2 million asthma-related visits to emergency departments/year Morbidity and Mortality (cont.) Race discrepancy Asthma prevalence is 39% higher in African Americans than in Caucasians Approximately 5,000 deaths from asthma yearly 80-90% of the deaths are PREVENTABLE 7

9 Indirect Costs of Asthma $4.6 billion Lost Productivity $1.7 billion 14.5 million lost work days 10 million missed school days Asthma impacts social and physical activities Indirect costs are especially important to employers Healthy People 2010 Asthma related goals Reduce asthma related deaths, hospitalizations, and emergency room visits Reduce activity limitations among persons with asthma Increase the proportion of persons with asthma who receive formal patient education, including information about community and self-help resources, as an essential part of the management of their condition 9

10 National Asthma Education and Prevention Program (NAEPP) Initiated by NIH in 1989 Has convened three expert panels First report in 1991 Revised edition in 1997 (EPR-II) Update on selected topics 2002 Revised edition in 2007 (EPR-III) Pediatric Asthma: Promoting Best Practice Guide for Managing Asthma in Children Coordinated by American Academy of Allergy, Asthma and Immunology, American Academy of Pediatrics, and NAEPP Published in 1999, updated in 2004 Recommendations based on NAEPP EPR-II Available at 10

12 Pathophysiology of Asthma Basic Review of the Pathophysiology of Asthma Old theory Airway hyperresponsiveness New theory Airway inflammation 12

13 A chronic airway disorder in which many cells and cellular elements such as macrophages, neutrophils, epithelial cells, mast cells, eosinophils, T lymphocytes and other cells play a prominent role. Asthma is characterized by airway hyperresponsiveness, airway inflammation, airway wall remodeling and bronchoconstriction which changes in severity spontaneously or as a result of treatment Episodes of asthma symptoms are usually associated with widespread but variable airflow obstruction that is reversible 13

16 Inflammatory Process Early Asthmatic Response (EAR) Due to mast cell degranulation in response to trigger IgE response results in preformed chemical mediator release Develops within 15 minutes of exposure and resolves within 2 hours Inflammatory Process Late Asthmatic Response (LAR) Further production of mediators Results in increased vascular permeability, vascular leakage, airway wall swelling and bronchospasm 3-8 hours after exposure and lasts for up to 24 hours 16

17 Asthma is no longer considered synonymous with bronchospasm or constriction. It is an inflammatory disease in which bronchospasm occurs secondary to airway inflammation Factors Contributing to Development of Asthma Genetic predisposition Male gender Having few older siblings Western environment Allergen exposure * *Appears to be most important factor 17

19 Signs and Symptoms of Asthma Classic Symptoms Wheezing High-pitched, whistling sound Created by turbulent airflow through obstructed airways Usually heard during expiration Interactive Check Point Which of the following is an often overlooked symptom of asthma? a. Rales b. Chest pain c. Palpitations d. Cough 19

20 Interactive Check Point Answer d. Cough In addition to wheezing, cough is one of the classic symptoms of asthma. It is a common and often overlooked symptom of asthma Rales, palpitations and chest pain are not typical symptoms of asthma Signs and Symptoms of Asthma Classic Symptoms Coughing Common and often overlooked Dry or productive May be only symptom Often seen in children 20

22 Signs and Symptoms of Asthma Highly variable between patients Episodic Generally worse at night and early morning May become irreversible over time Choose your option below. Next Topic: Diagnosis and Classification of Asthma 22

24 Diagnosis of Asthma History Have you had coughing, wheezing or shortness of breath (SOB): At night? In the early morning? After physical activity? Have you had these symptoms during a particular time of year? Have you used any medications to help you breath better? Diagnosis of Asthma Physical exam Chest auscultation Expiratory wheezes Decreased breath sounds Cough Patient using accessory muscles for respiration Evidence of allergy Eczema Nasal polyps Inflamed turbinates Eyelid edema 24

26 Critical Elements in the Diagnosis of Asthma History Reversible airway obstruction Classification of Asthma Based on severity of disease Symptom presentation Asthma severity is the intrinsic intensity of disease 26

27 How To Classify Asthma Severity BEFORE therapy is started Classify according to clinical features Includes domains of current impairment and future risk Helps guide clinical decisions on appropriate medication selection Domains Impairment Frequency and intensity of symptoms Functional limitations the patient is experiencing Risk Likelihood of either asthma exacerbations, progressive decline in lung function, or medication adverse effects 27

30 Advantages of a Classification System Aids in treatment selection Standardization for research studies Choose your option below. Next Topic: Application Exercise 30

31 Application Exercise Assessing Patient Symptoms and Classifying Asthma Severity Case Presentation Mrs. Jones is a 34 year old who comes to your pharmacy seeking something for a dry nonproductive cough. She does not have a fever or other symptoms of a respiratory infection. 31

33 Best Answer b. Cough Her dry nonproductive cough may be a symptom of her asthma not being well controlled but it also may be an adverse effect from her enalapril therapy. Case Presentation In addition to her cough, Mrs. Jones says she needs something to help her breathe better. She uses the inhaler at least 4 times daily because of shortness of breath and some wheezing during the day. She wakes at night with shortness of breath about twice a week. Based on prescription refill records she is using 2 inhalers per month. 33

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